|
Name
|
|
|
|
|
|
|
|
|
|
Phone #
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Address:
|
|
|
|
|
|
|
Email:
|
|
|
|
|
|
|
|
|
Date of Birth:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Referred by:
|
|
|
|
|
_______________________________________________________________________________________
|
|
|
|
Individual Month
|
|
|
|
|
|
|
|
Entire Year
|
|
|
|
|
|
|
|
If you don't wish to give your credit card information online, leave the fields blank, and someone will contact you. Note:
Without credit card information, no enrollment will be finalized until payment is received.
|
|
|
|
|
|
|
|
|
|
|
|
Credit Card #:
|
|
|
|
Total Amount Due
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Exp. Date:
|
|
|
|
|
|
|
|
|
|
|
Credit Card Identification Data (CID #)
|
|
|
|
|
|
|
Additional Comments:
|
|
|
|
|
|
|
|
By checking the statements below and entering your name in the "signature" box, you
are indicating in writing, your agreement with the terms and conditions of this
enrollment. Thank you!
|
|
|
|
|
|
I hereby accept all responsibility for any accident, injury, or illness that may occur in
conjunction with this program. I am releasing and hold harmless Premier Centre for the
Arts and all other parties involved from any and all claims, costs, liabilities and expenses
including all judgments, attorney’s fees and court costs. I understand that Premier Centre
for the Arts provides no medical insurance for the participants. I am executing this waiver
and release for my child/me to participate in this program.
|
|
|
|
|
|
I understand that a return check fee is $35. I understand that there are no refunds or
credits for tuition.
|
|
|
|
|
|
|
|
|
|
|
I understand that from time to time, PCA will photograph events and classes for
promotional purposes. I give PCA permission to use my/my child’s image and name for
promotional purposes.
|
|
|
|
|
|
Signature
|
|
|
|
|
|
|
|
|
|
|
|
|
